Accuracy of terminology and methodology in economic analyses in otolaryngology

Italian cost analysis of free flap surgery in head and neck reconstruction using the activity-based costing (ABC)

The aim of the study is to evaluate costs of free flap surgery for head and neck (H & N) reconstructions using the time-driven activity-based costing (ABC) method and to compare them with the refund provided by the Italian National Health System (NHS) amounting to 11,891€. We retrospectively selected 29 consecutive patients underwent free flap reconstruction in 2013 at IRCCS Casa Sollievo della Sofferenza. Patients were divided into three groups: Group 1 (n = 10) included patients receiving radial forearm free flap (RFFF), Group 2 (n = 10) receiving anterolateral thigh (ALT) free flap, and Group 3 (n = 9) composed of patients having fibular free flap. For each patient, costs were calculated using the ABC and divided into instay, surgical, and services costs. We observed an overall mean total cost of 27,802.40€. The mean costs related to hospital stay were 9,800.70€. The mean costs for surgery were 13,097.60€ and amounted to 4,904.10€ for services. RFFF appears to be less costing (25,175.40€) compared with ALT (29,191.60€) and fibula free flap (29,040.20€). ABC is an appropriate method to determine actual costs of free flap surgery by correctly allocating the resources used. The Italian NHS tariff seems to be inadequate to cover the real cost of this type of surgery.

Economic Analysis of the Treatment of Posterior Epistaxis

Background

The aim of this study was to compare the economic impact of controlling posterior epistaxis by transnasal endoscopic sphenopalatine artery ligation (TESPAL) and endovascular embolization.

Methods

We conducted a retrospective chart review of patients undergoing treatment of posterior epistaxis by either TESPAL or embolization. International Classification of Diseases 9 code 784.7 (epistaxis) was the initial screen followed by common procedural terminology codes for TESPAL and angiography with embolization. The total charges and direct costs for TESPAL and endovascular embolization were determined. An unpaired Student's t-test was used to evaluate statistical significance.

Results

Analysis revealed 25 patients that met inclusion criteria. The mean total charge was $14,088 for embolization and $7561 for TESPAL. The differences were statistically significant (p < 0.00006). Costs, defined as reimbursement by third-party payers and direct payments, varied widely and their difference did not reach statistical significance in this sample.

Conclusion

Our data established no economic advantage for angiography and, in fact, show a trend toward this treatment being more expensive than TESPAL. TESPAL is a procedure that can be performed quickly and on an outpatient basis without the need for angiography equipment or expertise. Additionally, the procedure provides the advantage of a comprehensive endoscopic nasal evaluation for ruling out tumors or other intranasal lesions. With equal efficacy, at least equal costs and equal risk, and additional diagnostic advantages, TESPAL is a more rational treatment for posterior epistaxis.

The Economic Burden and Symptom Manifestations of Chronic Rhinosinusitis

Background

The aim of this study was to delineate patient symptoms and economic burdens of chronic rhinosinusitis (CRS).

Methods

Adult patients with CRS were assessed prospectively with a survey instrument. Symptom scores for major and minor symptoms of CRS, medication use, physician visits for CRS, and work days missed were determined. Cost analyses were conducted.

Results

Three hundred twenty-two patients were studied prospectively (mean age, 42.3 years). Nasal obstruction and facial congestion were the most common and severe major symptoms, and headache and fatigue were the most common and severe minor symptoms. Patients received an average of 2.7 antibiotic courses and used nasal steroids and prescription antihistamines 18.3 and 16.3 weeks, respectively, in a 12-month period. Mean medical resource costs were $921 per patient-year. CRS caused an average of 4.8 days of missed work per 12-month period. The overall yearly economic cost of CRS was $1539 per patient.

Conclusion

Nasal and facial symptoms prevail over systemic and oropharyngeal symptoms in CRS. Significant medical resource expenditures and global economic costs accompany CRS.

Cost effectiveness of cochlear implants

PURPOSE OF REVIEW

Health professionals would be well served to have as good an understanding of cost effectiveness as clinical effectiveness, as both are critical to their patients having access to better health care and achieving better health outcomes. Cost-effectiveness evaluations allow decision makers a means of comparing different interventions when deciding resource allocation. It is a powerful tool, but like any analysis, not understanding the processes and assumptions involved leads to misinterpretation.

RECENT FINDINGS

Cost effectiveness is an economic evaluation of cost and benefit. The threshold at which an intervention is considered cost effective is reflected by the payer's "willingness to pay", which can vary considerably from country to country. These evaluations are complex and can involve the use of incomplete financial data, and subjective impressions of benefit, while excluding broader social and economic benefits.

SUMMARY

Pediatric unilateral and simultaneous bilateral cochlear implantation, and adult unilateral cochlear implantation are felt to be cost effective in the United States. Pediatric sequential cochlear implantation, adult bilateral cochlear implantation, implantation in the aged and the long deaf are not. However, cost-effectiveness economic evaluations are only part of broader assessment of social and economic benefit when determining resource allocation.

Reimbursement for reconstruction by tissue transfer-a European comparison

Background

Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. Our purpose was to analyse the reimbursement for different types of tissue transfer in five European countries.

Methods

We looked at common surgical options for pedicled and free flaps. The recipient site of a flap and the principal diagnosis were systematically modified and processed with national grouper software in order to identify Diagnosis-Related Groups from which the proceeds were derived. The primary data originated from the database of the German Institute for the Hospital Remuneration System as aggregate information. We conducted eight specialist interviews to transfer the available data into clinical practice. Data of real patients were not available and we rather simulated standard patients to avoid dilution of results.

Results

Altogether, payment for pedicled flaps averaged 5933€ and was 8517€ for free flaps. The comparison of both flap types within a country revealed significant differences in Germany, Austria and Sweden only (p < 0.001). Italy has the highest mean proceeds for pedicled flaps, followed by Sweden, Germany, Austria and the UK. This relationship changes for free flaps with Sweden achieving the highest payments. Overall, reimbursement conformity is higher for free flaps.

Conclusions

Most countries have procedure-driven payment systems for flap surgery, which additionally can strongly depend on the diagnosis. Nevertheless the latter does not always justify existing price differences. For the first time, clinical cases in tissue transfer were compared internationally. In today`s dynamic world of health care, we should observe other countries` compensation systems to identify ways of improving our own.

Bibliometric Analysis of Health Services Research in Otolaryngology Journals

Objective

Determine current health services research (HSR) publication trends in major general otolaryngology journals.

Study Design

Bibliometric analysis.

Methods

All main issues of 8 high-impact general-interest otolaryngology journals published worldwide in 2002, 2005, 2008, and 2011 were searched for HSR-related publications. To qualify as HSR, the abstract of the article must discuss access to care, cost, delivery of care, financing, health organizational or system issues, quality of care, resource utilization, and/or health outcomes. Otolaryngology topics were classified as general, pediatrics, oncology, otology and neurotology, sleep disorders, sinonasal disease, facial plastics, and/or laryngology. Other key measures included study authorship and external sponsorship or mechanism of support.

Results

Of 5958 total articles, 449 (7.5%) qualified as HSR. There was a statistically significant increase in the number of HSR publications across all journals from 2002 to 2011 ( P < .001). Outcomes research (337, 75.1%) was the most common type of HSR being published. The most common subject was oncology (112, 24.9%), whereas the least represented was trauma and facial plastics (4, 0.9%). First and corresponding authors were based in 31 countries, although the United States was the predominant country of origin. Nearly 95% of HSR articles in the current sample demonstrated multidisciplinary authorship. An estimated 22.9% of first authors and 17.8% of corresponding authors were female. Two-thirds of HSR publications reported no external sponsor, whereas the remainder was supported most commonly by philanthropy and hospital-based sources.

Conclusion

Health services research is an international, multidisciplinary field of inquiry with an increasing presence in major otolaryngology journals.

Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model

PURPOSE

1) To review our experience with office-based sedation/anesthesia for children with special healthcare needs who underwent dental rehabilitation at our institution. 2) To compare the cost to comparable patients who underwent similar procedures in the operating room.

PATIENTS AND METHODS

Retrospective review of patients' medical records and the sedation service database. Group CL: 114 patients who underwent office-based dental rehabilitation (135 procedures). Group OR: 23 patients who underwent dental rehabilitation under general anesthesia in the operating room for cost comparison.

OUTCOMES

1) EFFICACY (procedure completion rate and unplanned admissions); 2) SAFETY (complications and interventions); 3) Comparison of mean hospital charges billed between groups.

RESULTS

Demographics were similar in both groups. The most common specific underlying diagnoses were autism (38%), cerebral palsy/developmental delay (18%) and ADHD (4%) in both groups.

EFFICACY

procedure completion rate was 98.5% (2 aborted). There was 1 (0.7%) unplanned postanesthetic care unit admission due to an adverse drug event.

SAFETY

2 (1.5%) patients required invasive airway control. Eighteen (13.3%) patients developed transient hypoxemia. Twenty-three (17%) patients had airway obstruction needing simple intervention, and 1 (0.7%) patient had hypotension. There were no serious complications. Cost: mean total hospital charges were considerably higher in group OR ($6,126), versus group CL ($1,277), even after adjustment for inflation and length of procedure (P<.0001).

CONCLUSION

Office-based dental rehabilitation using a pediatric sedation service model in children with special needs is efficient, and can achieve average savings of $4,849 in hospital charges per patient.

Beyond efficacy and effectiveness: conducting economic analyses during clinical trials

Few studies have examined cost issues in the field of dysphagia. This study presents cost data collected during a clinical trial in speech-language pathology, demonstrating the types of cost analyses that can be conducted and highlighting obstacles and issues facing investigators who seek to conduct economic analyses in this arena. Seventy-nine patients were enrolled in the clinical trial to assess the impact of a swallowing intervention on swallowing and speech function. The patients were at least one year past treatment for head and neck cancer. No significant intervention differences were detected in these outcomes. A companion economic analysis was conducted in 37 of these patients using patient diaries and followup with identified health care providers. Analyses indicated that (1) the intervention did not significantly reduce health care expenditures; (2) indirect costs and costs of hospitalizations are both important factors to consider during a trial; and (3) health care costs of this population are high relative to the rest of the U.S. population. Attrition from the overall study population can pose a serious threat to the viability of an economic study. The article concludes with a discussion of how these issues can be addressed in future studies.